Kindly complete the form below to confirm your Local Service Registration

1

Company Name* This field is required

PressEnter

2

Representative Name

First Name

Last Name

PressEnter

3

Office Number* This field is required

Area Code

Phone Number

PressEnter

4

Mobile Number* This field is required

Area Code

Phone Number

PressEnter

5

Number to use inside Dolphin Coast 911* This field is required

Mobile Number

Office Number

Other

PressEnter

6

Phone Number* This field is required

Area Code

Phone Number

PressEnter

7

Email* This field is required

example@example.com

PressEnter

8

Website Address

PressEnter

9

Address* This field is required

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please Select

Please Select

United States

Afghanistan

Albania

Algeria

American Samoa

Andorra

Angola

Anguilla

Antigua and Barbuda

Argentina

Armenia

Aruba

Australia

Austria

Azerbaijan

The Bahamas

Bahrain

Bangladesh

Barbados

Belarus

Belgium

Belize

Benin

Bermuda

Bhutan

Bolivia

Bosnia and Herzegovina

Botswana

Brazil

Brunei

Bulgaria

Burkina Faso

Burundi

Cambodia

Cameroon

Canada

Cape Verde

Cayman Islands

Central African Republic

Chad

Chile

China

Christmas Island

Cocos (Keeling) Islands

Colombia

Comoros

Congo

Cook Islands

Costa Rica

Cote d'Ivoire

Croatia

Cuba

Cyprus

Czech Republic

Democratic Republic of the Congo

Denmark

Djibouti

Dominica

Dominican Republic

Ecuador

Egypt

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Falkland Islands

Faroe Islands

Fiji

Finland

France

French Polynesia

Gabon

The Gambia

Georgia

Germany

Ghana

Gibraltar

Greece

Greenland

Grenada

Guadeloupe

Guam

Guatemala

Guernsey

Guinea

Guinea-Bissau

Guyana

Haiti

Honduras

Hong Kong

Hungary

Iceland

India

Indonesia

Iran

Iraq

Ireland

Israel

Italy

Jamaica

Japan

Jersey

Jordan

Kazakhstan

Kenya

Kiribati

North Korea

South Korea

Kosovo

Kuwait

Kyrgyzstan

Laos

Latvia

Lebanon

Lesotho

Liberia

Libya

Liechtenstein

Lithuania

Luxembourg

Macau

Macedonia

Madagascar

Malawi

Malaysia

Maldives

Mali

Malta

Marshall Islands

Martinique

Mauritania

Mauritius

Mayotte

Mexico

Micronesia

Moldova

Monaco

Mongolia

Montenegro

Montserrat

Morocco

Mozambique

Myanmar

Nagorno-Karabakh

Namibia

Nauru

Nepal

Netherlands

Netherlands Antilles

New Caledonia

New Zealand

Nicaragua

Niger

Nigeria

Niue

Norfolk Island

Turkish Republic of Northern Cyprus

Northern Mariana

Norway

Oman

Pakistan

Palau

Palestine

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Pitcairn Islands

Poland

Portugal

Puerto Rico

Qatar

Republic of the Congo

Romania

Russia

Rwanda

Saint Barthelemy

Saint Helena

Saint Kitts and Nevis

Saint Lucia

Saint Martin

Saint Pierre and Miquelon

Saint Vincent and the Grenadines

Samoa

San Marino

Sao Tome and Principe

Saudi Arabia

Senegal

Serbia

Seychelles

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

Somalia

Somaliland

South Africa

South Ossetia

South Sudan

Spain

Sri Lanka

Sudan

Suriname

Svalbard

eSwatini

Sweden

Switzerland

Syria

Taiwan

Tajikistan

Tanzania

Thailand

Timor-Leste

Togo

Tokelau

Tonga

Transnistria Pridnestrovie

Trinidad and Tobago

Tristan da Cunha

Tunisia

Turkey

Turkmenistan

Turks and Caicos Islands

Tuvalu

Uganda

Ukraine

United Arab Emirates

United Kingdom

Uruguay

Uzbekistan

Vanuatu

Vatican City

Venezuela

Vietnam

British Virgin Islands

Isle of Man

US Virgin Islands

Wallis and Futuna

Western Sahara

Yemen

Zambia

Zimbabwe

Other

Country

PressEnter

10

Company Logo

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

Cancelof

PressEnter

11

Account Holder Details* This field is required

First Name

Last Name

PressEnter

12

Type of Identification* This field is required

ID Number

Passport Number

PressEnter

13

ID Number* This field is required

PressEnter

14

Passport Number* This field is required

PressEnter

15

Date of Birth* This field is required

PressEnter

16

Membership Options* This field is required

Basic Plan @ R385pm - 6 Months

Basic Plan @ R350pm - 12 Months

Premium Plan @ R495pm - 6 Months

Premium Plan @ R450pm - 12 Months

PressEnter

17

I accept that there is an initiation fee equal to the value of your monthly premium* This field is required

I Accept

PressEnter

18

Would you like us to debit the initiation fee together with the first months' premium?* This field is required

Yes

No

PressEnter

19

Optimize your Exposure on Social media even more for an additional R450pm* This field is required

Yes

No

PressEnter

20

Your Monthly Premium including VAT is:

PressEnter

21

Marketing Agency Name (If Applicable)

Dolphin Coast 911

Show me Ballito

PressEnter

22

Agent Name

PressEnter

23

Bank Name* This field is required

ABSA Bank

African Bank Limited

Bidvest Bank Limited

Capitec Bank Limited

FNB (First National Bank)

FirstRand Bank – A subsidiary of First Rand Limited.

Grindrod Limited

Imperial Bank South Africa

Investec Bank Limited

Nedbank Limited

SA Post Bank (Post Office)

Sasfin Bank Limited

Standard Bank of South Africa

PressEnter

24

Universal Branch Codes* This field is required

ABSA Bank - 632005

African Bank Limited - 430000

Bidvest Bank Limited - 462005

Capitec Bank Limited - 470010

FNB (First National Bank) - 250655

Investec Bank Limited - 580 105

Nedbank Limited - 198675

SA Post Bank (Post Office) - 460 005

Standard Bank of South Africa - 05100

Other

PressEnter

25

Branch Code

PressEnter

26

Type of Account* This field is required

Savings

Current/Cheque

Business Account

Investment Account

PressEnter

27

Account Number* This field is required

PressEnter

28

Debit Order Date* This field is required

1st

15th

25th

PressEnter

29

By signing and clicking Submit I fully acknowledge that I have read, understood and accept the terms and conditions of My Local Services. My Local Services is a product of ValueServ (Pty) Ltd.

ValueServ (Pty) Ltd and any 3rd party Services will not be held liable for any change in Emergency Numbers, Loss of signal or any features within the app that is not functioning because of poor reception.

I hereby instruct/authorize ValueServ(Pty) Ltd. to deduct the applicable monthly/annual debit from my bank account as provided by me herewith, and as per the payment, the frequency is chosen by me.

PressEnter

30

* This field is required

PressEnter

31

I Authorize ValueServ to debit my Account

I Accept

PressEnter

32

Signature

PressEnter

33

Date Signed

PressEnter

Should be Empty:

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to: